Provider Demographics
NPI:1023742632
Name:LAWRENCE, KELLI REBECCA
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:REBECCA
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 SAINT FERGUS DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5115
Mailing Address - Country:US
Mailing Address - Phone:580-618-4591
Mailing Address - Fax:
Practice Address - Street 1:200 N BRYANT AVE STE 120
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6273
Practice Address - Country:US
Practice Address - Phone:405-832-6881
Practice Address - Fax:833-941-1685
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2023-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKF07220309363LF0000X
OK209447363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily